J-1 Visa Waiver Application Instructions

General Instructions  

The J-1 Visa Waiver Applicant and Employer must provide information for all sections and subsection headings outlined below and order them in the completed application as they appear in the Application Package Content and Order listing below. Print or stamp the applicant physician's review or case number from the United States Department of State (DOS) on all application pages. 

1. Letter - Submit a letter signed by the administrator of the sponsoring employer for which the applicant physician will be employed to
    include the following: 

• Name of the sponsoring Employer and National Provider Identification (NPI) number
• Name of the J-1 Visa Waiver applicant physician and NPI
• Requests that California’s Department of Health Care Services (Department) act as an interested government agency and recommend a waiver for the J-1 Waiver applicant physician
• Describes the health facility including the nature and extent of its medical services.  Provide a description of the service area demographics including income, average Federal Poverty level, primary language, age make-up of residents, patient population mix, etc., how the employer and J-1 Visa Waiver applicants’ services is consistent with the Department’s mission, and other pertinent information to illustrate the community the physician will serve
• States the facility provides medical care to both Medicaid (Medi-Cal) or Medicare eligible patients and indigent uninsured patients. List the percentages of total patient population for each practice site (Medicaid, Uninsured, and Medicare)
• Describes the applicant physician’s qualifications, proposed responsibilities, and how his/her employment will satisfy important unmet health care needs of a medically underserved community
• Describe how the J-1 Visa Waiver applicant physician will provide services to a caseload that is comprised of at least 30% Medicaid (Medi-Cal) patients or a 30% caseload comprised of a combination of Medi-Cal and uninsured patients throughout the three year contract period
• Include a statement identifying the applicant's field of residency and the completion date
• Specialist application (only) effective July 1-September 30:  the sponsoring employers must state the "need" for the specialty position.  The sponsoring employer must describe the need for a proposed specialty at the worksite location(s) using population based data relevant to the proposed specialty (morbidity, mortality, population/physician ratio etc.) Please refer to the J-1 Visa Waiver Guidelines 
• Describe in chronological order how the health facility has attempted to locate qualified American physicians
• States unequivocally that the facility is offering the applicant physician at least three years of employment how the health facility will assure that the applicant physician will serve that need and describes the detailed plans for the applicant physician during and beyond the three year obligation
• Describes the effect on the underserved if the waiver application is denied
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    a.  Copy of a valid contract of employment signed and dated between the J-1 Visa Waiver applicant physician and the
         sponsoring health facility. The contract must include the following:     

• Name of the J-1 Visa Waiver applicant. and Include a description of the his/her services that they will provide ( i.e. Family practice, General Internal Medicine, Pediatrics, OB/GYN, General Psychiatry)

• States the J-1 Visa Waiver applicant will practice for at least three (3) years for no less than forty (40) hours per week providing primary care services

• States the applicant and employer will provide services to a caseload that is comprised of at least 30% Medicaid (Medi-Cal) patients or a 30% caseload comprised of a combination of Medi-Cal and uninsured patients throughout the three year contract period

• States the practice site(s) address and county.  If there are multiple practices sites, list each site with the address and days and hours at each site

• Identification of the salary for a J-1 Visa Waiver applicant must be listed in the contract and it must be equal to the prevailing wages of  the area.  (Refer to Foreign Labor Certification Data Center Online Wage Library for salary verification.) 

• The contract shall not include a non-compete clause enforceable against the applicant physician

• Include a statement that the J-1Visa Waiver applicant agrees to begin employment within ninety (90) days from the date the USCIS grants a waiver and approval to work

    b.  Copy of the health facility’s federally designated Health Professional Shortage Areas (HPSA), Medically Underserved  
         Areas/Populations (MUA/MUP) status or Health Professional Shortage Areas (MHPSA) status for psychiatrists 
         for all sites where the applicant physician will or might be providing services

    c.  Documentation from the local health care official (county health officer/director) stating the need for services of the applicant physician 

2. Information required from the J-1 Waiver applicant physician:   

    a.  Copy of the completed Waiver Review Application Data Sheet (form DS-3035)

    b.  Copy of The DOS File Number Notification (aka third party barcode page) and the DOS case number must appear on every page
         submitted with the application

    c.  Physician curriculum vitae (CV) that includes physician's name, address, date of birth, and city and country of birth

    d.  Letters of recommendation for J-1 Visa Waiver applicant physician

    e.  Copy of passage of examinations required by U.S. Citizenship and Immigration Services (USCIS): either Flex parts I and II OR all 3
         steps of the United States Medical Licensing Examination (USMLE)

    f.  Legible copy of California medical license OR a copy of the application to the Medical Board of California AND evidence of receipt
        by the Medical Board of California

    g.  Legible copies of all DS-2019 (formerly IAP-66) of the applicant physician covering every period (year) he/she was J-1 Visa status.
         Forms must be submitted in chronological order with the "Beginning a new program" first   

    i.   Four (4) separate attestations, signed and notarized (notary must include jurat verbiage. Please refer to Notary Handbook 2015
         for acceptable jurat verbiage):

• An attestation that the J-1 Visa Waiver applicant of his/her requirement to provide services to a caseload that is comprised of at least 30% Medicaid (Medi-Cal) patients or a 30% caseload comprised of a combination of Medi-Cal and uninsured patients throughout the three year contract period.  The sponsoring employer and J-1 Visa Waiver applicant physician must sign
• An attestation or statement of "No Objection": The applicant physician must submit a copy of a statement of no objection from their home government if he/she is contractually or financially obligated to return to the home country.  In the event that the applicant physician is NOT contractually or financially obligated to return to the home country, the applicant physician must submit a signed and notarized attestation to that effect
• An Attestation from the J-1 Visa Waiver applicant physician that he/she has not other waiver request pending with another government agency
• An attestation from the J-1 Visa Waiver applicant physician of his/her commitment to comply with J-1 Visa Waiver requirements

3. California Authorization for Release of Information (PDF) form with an original signature by the applicant physician. The applicant
     must identify the attorney, employer, or other designated recipient to discuss his/her J-1 Visa Waiver application

4. Federal G-28 or letter if represented by an attorney.

• Applications must be submitted in the order described above, separated by a tab divider page, and appropriately labeled with the name of the document.
• Submit two unbound single-sided copies of the complete application (one original, one copy) to the J-1 Visa Waiver Program.
• Do not include documents that are not required by DOS or the California J-1 Visa Waiver program.
• Applications are to be submitted to the J-1 Visa Waiver Program according to the instructions above. Please note that the Department will begin accepting applications on October 1st of each year. If October 1st falls on a weekend, applications will be accepted on the first business day following October 1st. Only applications received on or after the starting date will qualify for review and consideration.
• Each application must be shipped seperately. Shipments that contain more than one application will be returned.  

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